Page 1 of 9 MH 785 4/2019 MENTAL HEALTH PROCEDURES ACT OF 1976 (SECTIONS 304 AND 305) (The blanks below may be completed following admission) NAME OF PATIENT LAST FIRST MIDDLE AGE SEX NAME OF COUNTY PROGRAM NAME OF BSU BSU NO. NAME OF FACILITY ADMISSION DATE ADMISSION NO. INSTRUCTIONS 1. C omplete Part I(a) to petition for involuntary outpatient, partial hospitalization or inpatient treatment under Section 304(b) or (c). If the patient is currently receiving treatment , t his section must be completed by the director of the facility or his/her authorized representative . If the p erson is not currently receiving treatment , this section may be completed by any responsible party. Complete Part I(b) to petition for Assisted Outpatient Treatment (AOT) under Section 304(c.1) for a patient currently receiving inpatient treatment or under Section 305 (c) for patients currently receiving AOT . This section must be completed by the county administrator , treatment team or the director of the facility or his/her authorized representative. 2. Part II is to be completed by persons authorized by the director of the facility to explain rights to the patient if the patient is currently in treatment. If the patient is not currently in treatment, it should be left blank. (See No. 7 below.) 3. Part I II is to be completed on the basis of a current examination. If the patient is not currently in treatment and has not been examined this section may be completed on order of the court under Section 304 (c) (5) of Act 143. 4. Part I V is to be completed by the court. 5. If additional sheets are needed at any point, note on this form the number of pages , which are attached. 6. Attach a copy of the treatment plan (if any) and copies of the 302, 303 and 304 forms if previously completed prior to the delivery of this form to the court. 7. If a patient is not currently in treatment, he / she shall receive a copy of form MH 785 - B and a copy of this petition when he/she is notified of this hearing. 8. If the patient is subject to criminal proceedings/detention, briefly describe below. Note special use of f orm MH 786 for special criminal provisions. IMPORTANT NOTICE ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON PURPOSE WHEN COMPLETING THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 9 MH 785 4/2019 (305) PART I (a) PETITION FOR ORDER OF THE COURT h as acted in such a manner as to cause me to believe that (NAME OF PATIENT) he/she is severely mentally disabled. He/ she has been examined by an d was found to be in need of treatment. (NAME OF PHYSICIAN) He/she has not been examined by a physician, but I believe he/she is in need of treatment. I, therefore, request that: (Check and complete A, B , C , D or E ) A. As the patient is currently in receiving involuntary (NAME OF FACILITY) (304b) treatment under Section 303, I ask that the court issue an order that the patient be involuntarily committed for: outpatient, partial hospitalization, inpatient treatment. B. As the patient is currently in receiving involuntary (NAME OF FACILITY) treatment under Section 304 , I ask that the court issue an order that the patient be involuntarily committed for another period of: outpatient, partial hospitalization, inpatient treatment. C. As the patient is not currently in a facility receiving treatment, I ask this court to issue (304c) an o rder that the patient be involuntarily committed fo r: outpatient, partial hospitalization, inpatient treatment. D. A s the patient is currently in a facility receiving voluntary treatment, I ask this (304c) court to issue an order that the patient be involuntarily committed for: outpatient, partial hospitalization, inpatient treatment. (If the patient is currently receiving voluntary inpatient treatment and has given written notice of request to withdraw from treatment, the facility shall not hold the patient involuntarily longer than 72 hours without proceeding under Section 302. (See 50 P.S. 247 7304 (c) (6) and 55 Pa.Code 247247 5100.76 (a - c)). E. As the patient is currently in a facility receiving involuntary trea tment, I ask this (304g) co urt to issue an order that the patient be involuntarily committed for: outpatient, partial hospitalization, inpatient treatment. A patient can only be committed involuntarily if the patient is severely mentally disabled. A person is severely mentally disabled when, as a result of mental illness, his/her capacity to exercise self - control, judgement and discretion in the conduct of his/her affairs and social relations or to care for his/her own personal needs is so lessened that he/she poses a clear and present danger of harm to others or to himself or herself. Clear and present danger to others shall be shown by establishing that within the past 30 days the person has inflicted or attempted to inflict serious bodily harm on another and that there is reasonable probability that such conduct will be repeated. A clear and present danger of harm to others may be demonstrated by proof that the person has made threats of harm and has committed acts in furtherance of the threat to commit harm; or Clear and present danger to himself shall be shown by establishing that within the past 30 days: (i) the person has acted in such manner as to evidence that he/she would be unable, without care, supervision and the continued assistance of others, to satisfy his/her need for nourishment, personal or medical care, shelter, or self - protection and safety, and that there is reasonable probability that death, serious bodily injury or serious physical debilitation would ensure within 30 days unless adequate treatment were afforded under the act; or American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9 MH 785 4/2019 (ii) the person has attempted suicide and that there is the reasonable probability of suicide unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger may be demonstrated by the proof that the person has made threats to commit suicide and has committed acts which are in further of the threat to commit suicide; or (iii) the person has substantially mutilated himself/herself or attempted to mutilate himself/herself substantially and that there is the reasonable probability of mutilation unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger shall be established by proof that the person has made threats to commit mutilation and has committed acts which are in furtherance of the threat to commit mutilation. Describe the specific behavior of the patient within the last thirty (30) days which causes you to believe that he/she is severely mentally disabled. Use additional sheets if necessary . Signature of Petitioner Date Signature of Witness Date Address Phone American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 9 MH 785 4/2019 PART I (b) PETITION FOR ORDER OF THE COURT FOR ASSISTED OUTPATIENT T REATMENT (AOT) The patient was examined by (304 c.1) (Name of psychiatrist or licensed clinical psychologist) and was determined to no longer need involuntary inpatient treatment under Section 301 (b)(1) or (2) or treatment in a forensic facility or correctional institution. I believe this person is in need of AOT under Section 301 (c). The patient is currently receiving AOT provided by . I believe this (305 c) (NAME OF FACILITY) person is in need of an additional period of AOT under Section 301 (c). AOT is defined as community - based outpatient social, medical and behavioral health treatment services ordered by the court for a severely mentally ill person which may include community psychiatric supportive treatme nt, assertive community treatment, medication, individual or group therapy, peer support services, financial services, housing or supervised living services, co - occurring alcohol or substance abuse treatment, and any other services prescribed to treat the The p atient continues to need treatment under AOT based upon clear and convincing evidence that all